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Linda Collins Blogger

How to Document Functional Levels

Posted by Linda Collins | May 29, 2018

A lower limb prosthesis may be covered when there is documentation to support the patient will reach or maintain a specific functional level. The documentation must be corroborated in the physician's medical records. Simply stating the K level and definition is not sufficient.

A patient's functional level is based upon the evaluation of the prosthetist and treating physician. The assessment may include, but not be limited to,

  • a review of the patient's past medical history
  • prior prosthetic use
  • assistive devices used and when
  • the patient's current medical condition
  • co-morbidities
  • the condition of the residual limb
  • symptoms limiting ambulation
  • description of activities of daily living and how impacted by limb loss
  • gait
  • balance/coordination
  • strength
  • and the patient's desire to ambulate

 A Physician Worksheet for Prosthetic Documentation, which a tool to use when communicating documentation needs to the treating physician, may be downloaded under the Reimbursement Resource section of this page. 

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